How to Lose Weight with Phentermine, 5-HTP, exercise and motivational techniques: Dr. Jay Piatek

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Friday, November 21, 2003 6:00 am Email this article
Dr. Jay Piatek explains how he uses phentermine and 5-HTP plus exercise and some unique motivational techniques to help both adults and children achieve long-term weight loss.

How to Lose Weight with Phentermine, 5-HTP, exercise and motivational techniques: Dr. Jay Piatek

Dr. Jay Piatek explains how he uses phentermine and 5-HTP plus exercise and some unique motivational techniques to help both adults and children achieve long-term weight loss.

Roger (Jay) Piatek, M.D. runs a weight loss practice in Indianapolis, Indiana. He has treated over 4,000 patients in the past 4 years, most of whom came to him by word-of-mouth. Dissatisfied that some patients dropped out before reaching their goal weight, Dr. Piatek set out two years ago to understand why this was and what he could do about it. His research uncovered some unique motivational techniques—using pain and pleasure—to help patients lose weight long-term, that he found worked as well in children as it did in adults. Larry Hobbs interviewed Dr. Piatek by phone.

PIATEK PROGRAM

Hobbs:   How many patients have you helped lose weight?

Piatek:   A little over 4000. I see about 1000 patients per month.

Hobbs:   What is the average weight loss?

Piatek:   Three-fourths of patients who stay for at least six months lose at least 10 percent of their body weight. But I have stopped making weight the end point. I don’t focus on weight, except as a means to an end.

Hobbs:   How would you describe your program?

Piatek:   It’s a 4-prong approach consisting of diet, exercise, medication and motivation. Motivation is the most important, but all of the prongs are necessary. Picture yourself sitting on a chair. What will happen if I take one of the legs away? The chair will get weaker. If you take two legs away the chair will collapse. The same thing is true of my 4-prong program—if you take one of the elements away the program isn’t as strong and if you take two of the elements away the program will collapse.

Hobbs:   How is your program different than others?

Piatek:   It’s not weight-based, it’s outcome-based. We don’t focus on weight.

Hobbs:   So what do you focus on?

Piatek:    I focus on their outcome and their purpose. In order achieve a goal first you have to know what you want and why you want it. Knowing the reason why a person wants to lose weight is the most important. Everybody has a reason as to why they want to lose weight. Some want to feel sexier. Some want to feel more powerful. Some want to feel healthier. So I find out why each person wants to lose weight and that is what we focus on.

It’s like an Olympic athlete—they don’t work out for the sake of working out, they do it because they are focused on winning an Olympic medal. For an Olympic athlete eating a proper diet and exercising are a means to an end. Those are they things that they have to do to reach their goal. They are always focused on their outcome. I do exactly the same thing—I have patients focus on what they really want. Whatever feeling they are trying to achieve by losing weight, that is what we focus on.

Hobbs:   Has this approach made a difference in weight loss or how long patients stay?

Piatek:   Yes, definitely. A couple of years ago when I was prescribing Fen-Phen maybe half of patients lost 10 percent of their body weight. Now seventy-five or eighty percent of patients lose that much and they stay in the program longer. It has made a big difference.

Hobbs:   How did you decide to focus on outcome rather than weight?

Piatek:    Back in 1996 and 1997—in the days of Fen-Phen—some patients would stop short of their goal. They came in wanting to lose 60 pounds but would stop after three or four months after they had lost only 30 pounds. I tried to figure out why this was. Why did people stop short of their goal? It was frustrating for me because I wanted them to succeed. I didn’t want them to stop short. Then I finally came to realize that the reason that people stopped short was because they were focused on weight. They associated pain with being overweight. The primary reason that they were coming to me was because they were in pain. But for some people losing 30 pounds was enough to reduce their pain to the point that they stop coming. They became complacent. They felt it was good enough. Their level of pain was reduced enough that they lost their motivation. That’s when I realized that it wasn’t about weight, it was about pain. That’s why people were stopping short of their goal. That’s when I realized that the focus should be on outcome and not on weight.

Hobbs:   Do you individualize your program?

Piatek:   Yes, absolutely. I believe that there is a variation of the program that will work for everyone and it is my job to find out what that is for each patient. Some people need a different dose or a different medicine or different timing or a different exercise program. Or some people need to watch their fat intake or eat a little more protein at certain times to fill them up. But I make sure that patients know that I will keep working with them to find out what works best for them. If I try something and it doesn’t work with a particular patient then I try something else. I instill this in patients also—I tell them to try something and if it works great, but if it doesn’t then they need to try something else. This is exactly the same thing that successful businesses do—if one approach doesn’t work they try something else until they find what does. That’s exactly what I do with patients. Eventually everyone succeeds. I also act as a coach for patients.

Hobbs:   Explain your being a coach?

Piatek:   Everyone needs a coach. Even great athletes such as Tiger Woods or Michael Jordan need a coach to help them along the way. It’s easy to get lost in life. So I act as a coach for patients to help guide them when they get lost and help steer them in the right direction to achieve their goals.

PIATEK ON MOTIVATIONAL TECHNIQUES

Hobbs:   What motivational techniques do you use?

Piatek:   I use pain and pleasure to motivate patients to lose weight. Pain pushes people to do things whereas pleasure pulls them.

Hobbs:   How do you use pain to motivate?

Piatek:    Humans’ strongest motivation is to avoid pain. Our second strongest motivation is to seek pleasure. Patients come to me because their weight is causing them some sort of pain. It may be physical or it may be psychological, but the reason that they come to me is because of this pain. The pain may be that they feel embarrassed to be around people, or they feel that their spouse doesn’t see them as sexy any more, or they feel that their children are embarrassed by them, or that their weight is destroying their health. Whatever the pain is, that is the reason that they have come to see me. So one way that I help to motivate them is to ask questions and use imagery to associate this pain with their being overweight. In my experience the desire to avoid pain is about twice as strong a motivator as the desire to seek pleasure although both are powerful motivational forces.

Hobbs:   How do you form this association of pain with weight?

Piatek:   I have them associated pain with the behaviors that are causing their weight problem such as eating fattening foods and not exercising. I have them picture in their mind their most painful experiences due to their weight. For example, if they are embarrassed to be in front of people because of their weight I have them picture this. I have them imagine it in great detail. I want them to feel it, touch it, smell it—experience it as vividly as possible in order to elicit this pain that their weight is causing them. I want them to associate this pain with their being overweight. I have them focus on this pain several times a day because it is such a powerful motivator. I also use some pain-associating techniques to help patients break certain eating habits that are adding to their weight problem.

Hobbs:   For example?

Piatek:    For the first couple of weeks, every time a patient is going to eat something I have them ask themselves ‘Is this going to make me feel more sexy, or more powerful, or my kids proud of me, or whatever the reason is that they want to lose weight?’ This helps them to associate pain with certain eating habits that are adding to their weight problem and helps them to make better choices.

For example, one overweight woman came in and said that she ate ice cream every day. It was a pleasurable experience to her because she loved the taste, but it was also making her fat. So I wanted to break this association of ice cream and pleasure, and instead link it to pain. So I had her lift up her shirt and look at her belly—which she had told me was the worst part of her body—and take a bite of the ice cream and then imagine that her belly was getting bigger and bigger with every bite. I had her do it over and over. I wanted her to break her association of eating ice cream and pleasure, and instead link it to pain. I wanted her to associate eating ice cream with her pain of having a big belly so that she would never look at ice cream the same way.

Hobbs:   How do you use pleasure to motivate?

Piatek:    Pain pushes people to achieve their goal whereas pleasure pulls them. Pleasure is not as strong a motivator as pain—which is probably two or three times stronger—but they need pleasure to pull them the rest of the way once their pain has subsided. So I use pleasure to motivate in the same way that I do pain.

I use as many senses as possible to have them link pleasure with eating right, exercising and losing weight. For example, I ask them how it would feel to be down to their goal weight. I have them imagine it—to picture it in their mind. Then, which this image in their mind, I ask them ‘How do you feel?’, ‘How are your friends treating you?’, ‘How is your spouse treating you?’, ‘Are your children proud of you?’, ‘How do your knees feel?’ I want them to picture it, to experience it, to hear it, to touch it—to feel the pleasure of succeeding and associate that with losing weight. Since the second greatest motivator in our lives is to seek pleasure, I link the image of success and pleasure to help motivate them to achieve their goal. I have them think about it numerous times during the day. I have them almost obsess about it. I teach them that you get what you focus on. So if you focus on losing weight, that is what you are going to get.

Hobbs:   Do you use any other techniques?

Piatek:   Yes. I use a number of other techniques. I recently finished writing a book which includes a step-by-step guide of all the motivational techniques that I use.

Hobbs:   Have you noticed any secrets of success among your patients?

Piatek:   Yes. I’ve notice five secrets of patients who achieve long-term success.

1. They do it without willpower. They are so focused on their outcome that they make the right choices and lose weight without will power.

2. They never forget the pain of being overweight. They remember where they came from. It scares them straight.

3. The focus, or even obsess, on achieving their outcome.

4. They are constantly taking self-inventory such as keeping a food diary or exercise diary.

5. They all exercise.

Hobbs:   How do you determine progress without focusing on weight?

Piatek:   Every month I find out if they are closer to the outcome that they desire. Do they feel sexier? More powerful? More fulfilled? Or whatever it is that they really want. Weight loss comes as a by-product as they progress towards their goal.

Hobbs:   Do patients like focusing on outcome rather than weight?

Piatek:    Absolutely. Patients do better, they feel better, they’re more motivated, and they don’t quit. They keep coming back. With this new approach they know that they are going to reach their goal. People stick with it even if a month goes by and they don’t lose much weight. Before—in the Fen-Phen days when I was focusing on weight—if a month went by and they did not lose much weight patients would quit. They would stop coming. They thought ‘Well, the medications have stopped working so I might as well quit.’ But now that we focus on outcome they don’t quit. They keep coming. They know that it is just a bump in the road and that next month will be better. Focusing on outcome works much better than focusing on weight.

Many patients have also asked for cassette tapes so that they can listen to the motivational stuff more often then just once a month when they come in to see me. People seem to be thirsty for this information.

PIATEK ON WHEN TO TREAT

Hobbs:   What is your criteria for treating a patient?

Piatek:   I follow the recommendations of treating people when they are obese—having a body mass index (BMI) of 30 or more—or when they are overweight with comorbidities—a BMI of 27 or more—but I also treat people with a lower BMI of 25 depending on their weight history.

Hobbs:   How do you use weight history?

Piatek:   If their BMI used to be 20 or 21 and they have been gaining weight rapidly until now when their BMI is close to 25 I will treat them also. I feel it is important to stop it early and I feel that medicines such as phentermine, when used properly, are very safe.

PIATEK ON DIETING

Hobbs:   How important is dieting—consciously reducing calories—for losing weight?

Piatek:   Not very important. In my opinion it’s only about 20 percent of the answer. Dieting leads to short-term weight loss but it almost never lasts. This was part of the breakthrough that I had two years ago.

Hobbs:   What was your breakthrough as far as dieting?

Piatek:    I kept trying to figure out why most people fail to achieve long-term weight loss. When I came to understand that avoiding pain is our most powerful motivator, I suddenly realized why most people were failing. It’s because they focus on dieting, and dieting is painful. There is no pleasure in dieting. It’s painful to deprive yourself of what you want. And because it is painful it relies completely on will power. There are only a few people—those who are obsessive-compulsive—who are able to do this long-term. But for the overwhelming majority of people focusing on dieting will always cause them to fail. If you want to succeed dieting can’t be your focus.

Some of my patients say that they have been on 20 diets and obviously failed 20 times. Shouldn’t that tell them something? Shouldn’t it become obvious at some point that focusing on dieting doesn’t work? Yet, amazingly, people keep trying diet after diet after diet. It doesn’t work yet they keep trying it over and over. It seems insane to me.

PIATEK ON DIET MEDICATIONS

Hobbs:   Are diet drugs necessary?

Piatek:    No, they are not are absolutely necessary, but they are a powerful motivational tool. So I guess in a realistic sense I should say that they probably are necessary for most people. Remember the analogy to a chair and its 4 legs? Some people might be able to sit on a chair with one leg missing, but it would not be very stable. Medications greatly speed the results. You could ask the same question about antidepressants—Are they really necessary? Can’t people get over their depression simply by talking about their problems and working them through? Well, maybe, but shouldn’t we use medications that can help people?

Medications help to correct the imbalance in chemistry that drive weight gain. Some weight counselors say that motivation is all that you need, but in most cases I don’t agree. I’ve found that using motivation alone works in about 30 percent of people but adding medication increases that to about 80 percent.

People who are diabetic are told that they need to diet, exercise and take a pill. People who have high blood pressure are told to eat a low-salt diet, exercise and take a pill. So why should it be any different with obesity? It’s easy to say that diet, exercise and will power are all that you need, but it’s difficult for most people to do.

I think that in most cases diet medications are essential in the same way that antidepressant medications are an essential tool for helping patients to overcome depression. I think that the key is to combine medications and exercise. Diet medications are the tool that help people feel good about doing exercise. Without them many people don’t feel like exercising at the end of a long day, but with the medications they do.

Numerous studies have shown that exercise alone—that is, a realistic amount, an amount that people are willing to do—does not cause a significant amount of weight loss in most people. Therefore exercise becomes a painful, unrewarding experience. But patients do lose when you combine medications with exercise. I’ve seen it happen again and again and again.

Patients taking medicines in addition to diet and exercise always do better than patients on diet and exercise alone. Using medications as a tool together with motivational techniques takes the will power out of losing weight. Diet medications increase the response rate from about 30 percent to 80 percent.

I also help patients to understand that some of their overeating comes from craving certain foods. I help them to understand that the medications help to stop the cravings so that they can follow what they know they should do.

Hobbs:   What diet drugs do you use?

Piatek:   Mostly phentermine, but also some diethylpropion (Tenuate), some Meridia (sibutramine) and some phendimetrazine (Bontril)?

PIATEK ON PHENTERMINE

Hobbs:   How much do you use each brand of phentermine and what differences have you found?

Piatek:    I prefer Adipex (phentermine). I use it in about eighty-five percent of patients. It works better than the other forms of phentermine. It’s a little more stimulating than Ionamin and a lot more than Fastin—about 4 times as stimulating as Fastin in my experience. I have patients start with one-half tablet at 8 o’clock in the morning and increase it to 1 tablet—37.5 mg—after a week. If they experience hunger at night but not at noon I have them switch to taking it at noon. I do this because the effects of Adipex last for about 12 hours. Side effects occur in about ten percent of patients, but they tend to go away after a couple of weeks.

Ionamin (phentermine) lasts longer than Adipex. It lasts for about 18 hours. It’s not as stimulating as Adipex but I don’t use much of it because it is too expensive. I only use it in about 10 percent of patients, those that can’t take Adipex because of side effects such as people with panic disorder, anxiety or those who are stressed out.

I don’t use much Fastin (phentermine). I only use it in about 5 percent of patients. I use it in patients who find that Adipex is too stimulating. I also use it in the afternoon when a patient has excessive night time hunger—I have them take an Adipex in the morning and a Fastin in the afternoon. This works because Fastin is the shortest-acting of the name-brand phentermine’s. It’s effects last for about 8 to 10 hours and it’s only about one-fourth as stimulating as Adipex. So even if they take it in the afternoon its effects will still wear off by the time they go to bed.

Hobbs:   Have you had any strange side effects from Adipex?

Piatek:   Yes, I’ve had a couple of patients who said that Adipex makes them feel tired, not stimulated. I haven’t figure out why.

Hobbs:   Do you use generic phentermine?

Piatek:   Sometimes. However I found that several of the generics did not work as well as others.

Hobbs:   Which generic phentermine’s did not work for you?

Piatek:   The generic yellow capsules that patients got at Wallmart did not work.

Hobbs:   Which generic phentermines have you found effective?

Piatek:   The 15 mg green-and-yellow capsules and the 30 mg blue capsules. Some patients have said that the generic Adipex seem to work even better than the real Adipex.

Hobbs:   Do you have any patients taking more than 37.5 mg of phentermine?

Piatek:   Yes. I have a few patients who are taking two or three Adipex—75 to 112 mg per day. They simply did not respond to 37.5 mg. A higher dose really helps some patients. A number of patients have told me that taking an extra half an Adipex—18.75 mg—makes a big difference. One patient taking 37.5 mg of Adipex per day lost only one pound in the first month. When I doubled the dose she lost seven pounds the next month. It made a huge difference. I probably have about thirty patients taking 2 or 3 times the standard dose and every one of them says that it works better and side effects have not been a problem at all.

Hobbs:   Do you ever adjust the dose depending on the time of the month for a woman?

Piatek:   Yes. If a woman tells me that she has problems with her appetite one week a month then I have her take an additional half an Adipex—18.75 mg—and an extra 50 mg of Adipex during that week.

PIATEK ON MERIDIA (sibutramine)

Hobbs:How much Meridia do you use?

Piatek:   Some but not a lot. Meridia (sibutramine) is so expensive. I’ve found that most patients need 30 mg—the dose that was used in most Meridia studies—rather than the recommended dose of 15 mg. And the smaller doses—5 mg and 10 mg—are completely ineffective. In my experience Meridia is only about one-fourth as stimulating as Adipex (phentermine), however, Meridia is one of only two medicines on the market—the other being 5-HTP—that reduces sweet cravings especially using 30 mg of Meridia. The SSRI’s such as Prozac are helpful in cases of stress-eating, but they are not effective for reducing sweet cravings.

Hobbs:   Do you try to identify responders from non-responders, that is those who lose at least 4 pounds in 4 weeks?

Piatek:   No. When people lose less than this it just means that their chemistry is not right. I don’t stop the medicines in those people, I simply adjust the dose or add 5-HTP and work on techniques to reduce their stress in order to try and get their chemistry right. Everyone loses weight eventually when you get their chemistry right.

PIATEK ON XENICAL (orlistat)

Hobbs:   What is your experience with Xenical?

Piatek:   I rarely use Xenical (orlistat). The studies show that the weight loss is modest, at best, which does not justify its cost.

PIATEK ON PHEN-PRO

Hobbs:   Do you ever add Prozac or other SSRIs to phentermine—Phen-Prozac, Phen-Zoloft, Phen-Celexa, Phen-Effexor—in an attempt to increase weight loss?

Piatek:   Not very often. I only add SSRI such as Prozac (fluoxetine) when patients are depressed or when they are stress eaters. Occasionally I will add Effexor (venlafaxine) if a patient has trouble sleeping due to the phentermine.

PIATEK ON DIETHYLPROPION (Tenuate)

Hobbs:   Do you use diethylpropion (Tenuate)?

Piatek:   Yes. I use it in about 5 percent of patients—those that cannot tolerate Adipex (phentermine). Tenuate (diethylpropion) is only about one-forth as stimulating as Adipex. When I give it I use 75 mg of sustained-release Tenuate once a day.

PIATEK ON PHENDIMETRAZINE (Bontril)

Hobbs:   Do you use phendimetrazine (Bontril)?

Piatek:   Yes, but only in a few patients. It seems to work very well. I give 35 to 70 mg of the short-acting phendimetrazine three times per day rather than 105 mg of the long-acting at lunch. I do this to try and remind people to think about what they are eating three times per day. I ask them right up front if they can remember to take a pill three times per day to try and determine if compliance will be a problem, but for most people it is not. Phendimetrazine is not as stimulating as Adipex (phentermine) in my experience.

PIATEK ON 5-HTP

Hobbs:   Do you ever combine phentermine with 5-HTP?

Piatek:   Yes.

Hobbs:   How often?

Piatek:   I use it in about 80 percent of patients—those patients who crave carbohydrates or sweets.

Hobbs:   Does it help?

Piatek:   Yes, but dosing is important.

Hobbs:   What dose do you use?

Piatek:   50 mg to 300 mg. I’ve found that 50 mg is not enough for most women or sweet cravers.

Hobbs:   Have you noticed a difference between males and females?

Piatek:    Yes. Most men don’t have serotonin problems and don’t benefit from 5-HTP whereas most women do. I’ve found that only about 10 percent of men—those that crave sweets—benefit from 5-HTP and 50 mg is usually enough for them. The problem that most men have is craving fried, fatty foods and Adipex (phentermine) is great for stopping these cravings. There is always a dose of Adipex (phentermine) that will stop these cravings in a matter of weeks.

However, most women—probably about 80 percent, those that crave sweets—do benefit from 5-HTP and they usually need more than 50 mg.

Hobbs:   How do you decide when to use it?

Piatek:   When a patient has sweet cravings. I don’t use it specifically for weight loss—phentermine is the weight loss drug—but I use it to reduce sweet cravings so that patients are able to follow the techniques that they have learned.

Hobbs:   How do your results compare with Fen-Phen?

Piatek:   I’m getting better results with Phen-5-HTP than I did with Fen-Phen. But it’s not because 5-HTP is more effective than fenfluramine—it’s not—it’s just that now that I focus more on motivation whereas before I did not.

Hobbs:   When do you have patients taking 5-HTP?

Piatek:   They start with 50 mg in the evening between dinner and bedtime. After a week they increase it to 100 mg in the evening if needed. Then after five days, if they continue to be hungry or have sweet cravings, I add 50 mg in the morning in addition to the 100 mg in the evening. I allow them to increase it by 50 mg every five days, if necessary, first increasing the evening dose and then increasing the morning dose to a maximum of 300 mg per day—150 mg in the morning and 150 mg in the evening. I have them adjust the dose until they get a feeling of fullness and eliminate their sweet cravings.

Hobbs:   When do it’s effects peak?

Piatek:   About 3 hours after taking it. So another way to dose it is to have patients take it 2 or 3 hours before the time that they normally get their cravings.

Hobbs:   Do you combine Meridia with 5-HTP?

Piatek:   No.

Hobbs:   How often do you get side effects with 5-HTP—nausea, headaches, etc.?

Piatek:   Not very often—maybe in less than 10 percent of patients. If nausea is a problem for someone I have them use sublingual 5-HTP or take it with a carbohydrate.

Hobbs:   Have you had any problems with daytime sleepiness?

Piatek:   Very few.

Hobbs:   Any problems with sexual dysfunction?

Piatek:   No.

Hobbs:   Have you had any suspected cases of serotonin syndrome?

Piatek:   No.

Hobbs:   How do you recommend 5-HTP be taken?

Piatek:   I recommend taking it on an empty stomach or with a carbohydrate such as orange juice or crackers.

Hobbs:   Do you give any vitamins with 5-HTP?

Piatek:   Yes. I recommend a multiple vitamin to help with the conversion of 5-HTP to serotonin.

Hobbs:   Have your tried combining 5-HTP with carbidopa as suggested by Richard Rothman (ORU, Sept 99, p. 65)?

Piatek:   No.

PIATEK ON LENGTH OF TREATMENT

Hobbs:   Do you have patients take phentermine and 5-HTP indefinitely?

Piatek:   No. Everyone eventually comes off the medications.

Hobbs:   When do they stop?

Piatek:   When they have reached their goal weight. This may take two or three years for some patients, but eventually everyone comes off the medications.

Hobbs:   Do you take them off drug therapy if they stop losing?

Piatek:   No. We never stop short of their goal. I just keep changing their strategy until I find what works.

PIATEK ON PULSE THERAPY

Hobbs:   Do you ever put patients back on drugs if they gain weight?

Piatek:   Yes. In fact, that is the second secret of long-term success—‘knowing when to pull the trigger.’ I keep in touch with patients every three months to make them accountable. I teach them that once they regain 10 to 25 percent of the weight that they have lost—or whatever amount that they find unacceptable—they need to ‘pull the trigger’ and start the program again which includes taking the medicines. They usually only need it for a month or two until they lose the weight they’ve regained. This is essential for long-term success. This threshold—the amount that people allow themselves to regain—varies among patients, but those with the lowest threshold—people who panic when they gain 5 pounds—are the most successful long-term.

Hobbs:   What is ‘Pulse Therapy’?

Piatek:   Giving the medications when the need it and taking them off when they don’t. I would rather have patients taking medicines a couple of times a year rather than every day for the rest of their life.

PIATEK ON EXERCISE

Hobbs:   How important is exercise?

Piatek:   Very important. Exercise combined with medication is the key to success. But it has to be part of the entire program because exercise alone doesn’t work. Also losing weight with medications alone, that is without exercise, is limited to about 3 or 4 pounds per month. Some physicians may get more than this by using a strict diet but in most cases it doesn’t last because dieting doesn’t work. The key is combining exercise and medication.

Hobbs:   What do you mean that exercise alone doesn’t work?

Piatek:    Exercise alone doesn’t work for the average person trying to lose weight. The idea that small changes in daily living—such as walking up the stairs or parking at the far end of the parking lot—will cause a significant amount of weight loss is simply not true for most people. It simply doesn’t work. Walking is great for health and great for reducing stress, but too much time is required—more than most people are willing to do—to have an effect on weight.

For example, the research suggests that you have to walk about an hour-and-one-half per day, to have an effect on body weight. That’s about 5 or 6 miles or 10,000 steps. Most people are simply not willing to exercise this much.

Hobbs:   What do you mean that exercise is absolutely essential?

Piatek:   Every one of my patients who succeeds in losing weight long-term attributes most of their success to exercise. But it is important to find the ‘right’ exercise for each person and the right amount.

Hobbs:   What is the ‘right’ exercise?

Piatek:   Whatever activity a person loves to do. It can’t be something that is painful. It goes back to pain and pleasure. If they love it—if it’s pleasurable—they’ll keep doing it. But if they don’t love it—if it is painful and it requires will power to force them to do it—eventually they will stop. I have patients rate various physical activities on a scale of 1 to 10. I tell them to pick activities that they rate to be at least 7 or greater—things that they enjoy doing so it’s not a chore and it is something that they will do everyday. That’s they only way that they will continue doing it. I also have them think of ways to make it more pleasurable such as exercising with music or with friends so that they are more likely to do it.

Hobbs:   Do you recommend strength training?

Piatek:   Yes. I recommend some type of strength training—weight lifting—twice a week, but no more often than that and cardiovascular training four times a week. I recommend that with weight lifting they work up to 20 repetitions.

Hobbs:   Why only twice a week?

Piatek:   Adequate rest is essential. In fact, I have a great example of how overtraining doesn’t work. I have a female patient who was exercising seven days a week two hours a day and lifting weights five days a week before she met me. She had gone from 271 pounds to 249 pounds but was stuck there for a year. I put her on Adipex (phentermine) and convinced her to reduce her weight lifting to only twice a week and vary her exercise routine. Over the next eight months she lost 100 pounds.

Hobbs:   Do you have any examples of patients who include exercise and those who don’t?

Piatek:   Yes. One woman lost 4 times as much when she exercised as when she didn’t. The first time she started the program which included Adipex (phentermine) she lost 24 pounds in six weeks. Eventually she stopped coming, gained all her weight back, and then came back months later. She started on exactly the same program including Adipex but this time she only lost 6 pounds in six weeks. I asked her what the difference was and found out that she had hurt her knee and couldn’t exercise.

Hobbs:   What happens if people stop exercising?

Piatek:   They gain 3 or 4 pounds a month. I tell my patients this right up front so that they know exactly what to expect—if they want to keep the weight off they have to exercise.

PIATEK ON STRESS

Hobbs:   How do you help a patient deal with stress?

Piatek:   I have a 23-step process that I take them through in order to reduce stress. It involves helping them change their perception of stress so that they interpret things differently. I teach them techniques to deal with stress so that it balances their brain chemistry so it doesn’t lead to overeating. They become stress-exercisers or stress-non-eaters rather than being stress eaters like they used to be. It is important to deal with it because stress decreases serotonin and increases the stress hormone cortisol.

PIATEK ON BREAKING PLATEAUS

Hobbs:   Do you have any tricks for helping patients break through plateaus?

Piatek:   Yes. There are 3 techniques that I use. First, I have patients keep a diary so that I can look for something that has changed in their life. This is almost always the case. I’d say in 99 percent of cases when a patient plateaus or says that the medications are not working it is because of some problem that has come up in their life. It may be marriage trouble or financial trouble or difficulty at work or problems with their kids, but almost always it is caused by some kind of stressful situation in their life. I help them recognize this and figure out what they need to do. The other two techniques that I use for plateaus are using high-protein meal replacement shakes and using increasing doses of phentermine.

PIATEK ON MEAL REPLACEMENTS

Hobbs:   What type of meal replacement shakes do you use?

Piatek:   High-protein meal replacement shakes from HMR—Health Management Resources. They never cause weight gain. They always cause weight loss. Patients love them. Patients who are stuck on a weight plateau and can’t seem to lose always lose 2 to 5 pounds per week by using the shakes depending on how many they use per day.

Hobbs:   How do the HMR shakes compare to SlimFast?

Piatek:   They have 70 fewer calories and twice as much protein as SlimFast—15 grams versus 7 grams—and they taste much, much better. I can hardly keep them in stock.

Hobbs:   How do patients use them?

Piatek:    The easiest way is to have them drink a shake before their main meal of the day to kill their appetite. It reduces their intake by 500 to 800 calories per meal. Another way is to use 3 shakes per day for a week or two—one for breakfast, one for lunch and one before dinner. Some people use this technique one week a month. Using three shakes per day causes a weight loss of 2 or 3 pounds per week.

Another way is to use 5 shakes per day in place of meals for a week or two. This causes a weight loss of about 5 pounds per week. The only time that I allow patients to use them longer than a week or two is diabetics who are taking medicines that are making them fat. I let them use the HMR shakes in stead of eating until the lose 15 or 20 pounds which lets them get off of their diabetes medicine. This is one exception where I do focus on weight in the short-term.

Hobbs:   Do people get tired of the taste?

Piatek:   No, because we make up recipes with them to vary the taste. They can add orange flavoring or Crystal Lite or soda or fruit to change the flavor.

(Note: Dr. Jerry Darm said the same thing about HMR—‘I’ve looked at the Optifast and Medifast, but I consider HMR’s program to be the best
6 I think their shakes are the best, and believe me, I’ve tried a lot of different ones.’ (ORU, Mar 99). HMR can be reached at Health Management Resources, 59 Temple Place, Suite 704, Boston, MA 02111, phone (800) 418-1367 or (617) 357-9876, by fax at (617) 357-9690 or on the web at http://www.yourbetterhealth.com).

PIATEK ON FIBER SUPPLEMENT

Hobbs:   Have you found any other supplements effective in aiding weight loss?

Piatek:    Yes. Glucomannan which is a gel-forming, water-soluble fiber. I used to use it more—in about 20 percent of patients—but I don’t use it much any more since I started using 5-HTP. I will use it in people who are taking the HMR meal replacement shakes if they say that they are still hungry.

Hobbs:   What dose of glucomannan do you use?

Piatek:   Three or four capsules—1,500 to 2,000 mg—before a meal or with one of the HMR shakes.

PIATEK ON TREATING CHILDREN

Hobbs:   Do you treat children?

Piatek:   Yes.

Hobbs:   That’s rare, isn’t it?

Piatek:   Yes. There are only 21 centers in the country that treat pediatric obesity.

Hobbs:   Do you find children difficult to treat? A number of physicians have told me that they don’t treat children because they find it too difficult. They say that children see the world differently than adults.

Piatek:   No, I don’t find children difficult to treat at all. In fact, I find that they are very easy. Every child responds. I have some great letters from children saying how the program has changed their life. I included several of these stories in the book.

Hobbs:   Do you treat children differently than adults?

Piatek:   No. I treat them the same way—using pain and pleasure to motivate them.

Hobbs:   Why do you think that other physicians find children difficult to treat?

Piatek:   Because they tell them that they have to use will power. It doesn’t work. They have tried this their whole life and they know that it doesn’t work. The kids are sick of it. The parents are sick of it. Telling them to use will power is putting the blame on the kids. It tells them that it was their fault that they failed. But it’s not their fault. I tell every child this—I let them know that it was not their fault. It’s just that they were told to do something that doesn’t work. I think that is why others find children difficult to treat—they are going about it the wrong way.

Hobbs:   Do you have children exercise?

Piatek:   Yes. I require that they exercise 7 days a week, but I make sure that it is something that they enjoy doing such as jumping rope or using a mini-trampoline.

Hobbs:   Do you get parents involved?

Piatek:   Yes. I’ve found that it is as important to educate the parents as it is the children. That way they can be supportive such as buying the right foods.

Hobbs:   Do you use drugs on children?

Piatek:   Yes. One-half an Adipex (phentermine)—that is 18.75 mg—and 50 mg of 5-HTP if they are sweet cravers.

Hobbs:   For how long?

Piatek:   Usually 6 to 9 months.

Hobbs:   Does it worry you to use drugs in children?

Piatek:   No. I asked myself if would give these medications to my own children and the answer is yes, I would. I think that there is very little risk associated with phentermine. In fact, I heard a talk at Harvard where they refused to give a 400 pound girl medications because they were afraid that she would become dependent on them. So they want me to believe that it is better that she stay fat and die? The idea is completely illogical.

Hobbs:   How much weight loss have you seen in children?

Piatek:   60 to 80 pounds in children who are fifteen- or sixteen-years-old.

PIATEK ON CHANGING THE DRUG LAWS IN INDIANA

Hobbs:   Did you help get the law changed regarding diet drugs in Indiana?

Piatek:   Yes.

Hobbs:   How did you accomplish that?

Piatek:   We hired a lobbyist. I think it also helped that some of my patients are lawyers, judges and police. The first time we tried to get it changed the governor refused to sign it into law, but we went back a second time and got it passed. The law used to be that you could only prescribe a diet drug for a patient for three out of every twelve months. The current law is only good for two years and then it has to be reviewed again.

DR. PIATEK’S BOOK ‘THE OBESITY CONSPIRACY’

Hobbs:   What is the book that you are writing?

Piatek:   It is called The Obesity Conspiracy. In it I explain in detail all of the techniques that I use for helping patients lose weight. I also tell what really happened with fenfluramine, Redux and heart valve damage.

Hobbs:   When will it be out?

Piatek:   Soon.

—END

Articles on the same subject can be found here:

• 5-HTP (5-Hydroxytryptophan)

• Exercise

• Interviews with Doctors

• Motivational techniques for losing weight

• Phentermine